Advanced melanoma presentation and disease-specific survival disparities among disaggregated Asian American, Native Hawaiian, and Pacific Islander populations
Authors: Daniel Y. Kim, Edward C. Dee, Iona Cheng, Rebecca I. Hartman
Journal: Journal of the American Academy of Dermatology (2023)

To the Editor: Asian American (AA) individuals are the fastest-growing racial population in the United States, projected to reach 46 million by 2060.1Key facts about Asian Americans | Pew Research Center.https://www.pewresearch.org/fact-tank/2021/04/29/key-facts-about-asian-americans/Date accessed: June 9, 2022Google Scholar Despite reduced melanoma risk, AA patients have poorer prognoses compared to non-Hispanic White patients.2Zheng Y.J. Ho C. Lazar A. Ortiz-Urda S. Poor melanoma outcomes and survival in Asian American and Pacific Islander patients.J Am Acad Dermatol. 2021; 84: 1725-1727https://doi.org/10.1016/J.JAAD.2020.08.086Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar Existing melanoma research commonly aggregates AA and Native Hawaiian and Other Pacific Islander (NHOPI) individuals into a single category, limiting knowledge surrounding differences in melanoma outcomes among disaggregated AA and NHOPI populations.3Shah N.S. Kandula N.R. Addressing Asian American misrepresentation and underrepresentation in research.Ethn Dis. 2020; 30: 513https://doi.org/10.18865/ED.30.3.513Crossref PubMed Scopus (44) Google Scholar We examined differences in stage at diagnosis and melanoma-specific mortality among aggregated and disaggregated AA and NHOPI populations within the Surveillance, Epidemiology, and End Results 17-registries program to characterize their melanoma-related health disparities. We identified 206,707 AA, Native Hawaiian, Pacific Islander, and non-Hispanic White patients with first histologically confirmed primary malignant cutaneous melanoma diagnosed from 2004 through 2019 (Supplementary Fig 1, available via Mendeley at https://doi.org/10.17632/k48ycg497h.1). χ2 and Kruskal-Wallis tests were performed to examine differences in demographic variables among populations. Unadjusted Kaplan-Meier survival analyses and log-rank tests assessed melanoma-specific survival differences. Multivariable logistic regression and Cox proportional hazards models were performed to examine stage at diagnosis and melanoma-specific mortality, respectively, comparing each disaggregated population to both non-Hispanic White and Chinese patients. Overall, AA and NHOPI individuals were generally younger and had higher rates of acral lentiginous and lower extremity melanoma (Supplementary Tables I and II, available via Mendeley at https://doi.org/10.17632/k48ycg497h.1). When examining stage at diagnosis, aggregated AA and NHOPI populations were significantly more likely to present with distant metastases than non-Hispanic White patients (adjusted odds ratio [aOR] = 2.76, 95% confidence interval [CI] = 2.20-3.47) (Table I). Among disaggregated groups, Filipino (aOR = 3.81, 95% CI = 2.37-6.13), NHOPI (aOR = 3.93, 95% CI = 2.36-6.54), and Vietnamese patients (aOR = 8.69, 95% CI = 4.35-17.40) had significantly higher odds of distant metastases than non-Hispanic White patients. This was also observed compared to Chinese patients among Filipino (aOR = 3.33, 95% CI = 1.49-7.47) and Vietnamese patients (aOR = 7.69, 95% CI = 2.93-20.20) (Table I). Regarding survival, we observed significant survival differences among populations, with the lowest 5-year melanoma-specific survival rate observed in Vietnamese patients (68%) (Fig 1). In adjusted analyses, aggregated AA and NHOPI patients had significantly greater melanoma-specific mortality than non-Hispanic White patients (adjusted hazard ratio [aHR] = 1.59, 95% CI = 1.42-1.78). Among disaggregated groups, Filipino (aHR = 1.64, 95% CI = 1.28-2.10) and NHOPI (aHR = 1.88, 95% CI = 1.44-2.46) patients had greater melanoma-specific mortality than non-Hispanic White patients (Table I).Table IMultivariable logistic regression and Cox proportional hazards models of Asian American, Native Hawaiian, and Other Pacific Islander populations on melanoma stage at diagnosis and melanoma-specific survival, respectivelyStage at diagnosis∗Multivariable analyses were adjusted with age, sex, histologic subtype, anatomic site, median household income, rurality, and geographic location, with stage at diagnosis and receipt of first-line surgery included as additional covariates in survival analyses.Melanoma-specific mortality∗Multivariable analyses were adjusted with age, sex, histologic subtype, anatomic site, median household income, rurality, and geographic location, with stage at diagnosis and receipt of first-line surgery included as additional covariates in survival analyses.LocalizedRegionalDistantaOR (95% CI)aOR (95% CI)aOR (95% CI)aHR (95% CI)Non-Hispanic White vs AA and NHOPI population (sample size) Non-Hispanic White†Reference levels were selected based on known group with largest number of patients. (205,198)ReferenceReferenceReferenceReference AA and NHOPI (1509)0.41 (0.36, 0.47)∗∗∗1.91 (1.67, 2.19)∗∗∗2.76 (2.20, 3.47)∗∗∗1.59 (1.42, 1.78)∗∗∗Non-Hispanic White vs disaggregated AA and NHOPI populations (sample size) Non-Hispanic White†Reference levels were selected based on known group with largest number of patients. (205,198)ReferenceReferenceReferenceReference Chinese (261)0.41 (0.30, 0.55)∗∗∗2.44 (1.82, 3.28)∗∗∗1.22 (0.65, 2.29)1.46 (1.11, 1.93) AIP (92)0.32 (0.20, 0.52)∗∗∗2.25 (1.33, 3.80)∗∗4.25 (1.90, 9.51)∗∗∗1.22 (0.77, 1.94) Filipino (245)0.34 (0.25, 0.46)∗∗∗1.98 (1.44, 2.71)∗∗∗3.81 (2.37, 6.13)∗∗∗1.64 (1.28, 2.10)∗∗∗ Japanese (169)0.53 (0.35, 0.79)∗∗1.64 (1.07, 2.50)2.12 (0.99, 4.54)1.64 (1.17, 2.29) Korean (101)0.47 (0.29, 0.78)∗∗1.87 (1.13, 3.11)1.73 (0.66, 4.52)1.78 (1.20, 2.63) NHOPI (260)0.45 (0.33, 0.62)∗∗∗1.50 (1.06, 2.13)3.93 (2.36, 6.54)∗∗∗1.88 (1.44, 2.46)∗∗∗ Vietnamese (68)0.15 (0.09, 0.25)∗∗∗3.41 (1.98, 5.90)∗∗∗8.69 (4.35, 17.40)∗∗∗1.79 (1.15, 2.77) Other (313)0.56 (0.41, 0.76)∗∗∗1.54 (1.12, 2.12)1.98 (1.14, 3.44)1.40 (1.04, 1.87)Chinese vs disaggregated AA and NHOPI populations (sample size) Chinese†Reference levels were selected based on known group with largest number of patients. (261)ReferenceReferenceReferenceReference AIP (92)0.74 (0.42, 1.33)0.91 (0.50, 1.68)3.54 (1.23, 10.10)0.98 (0.55, 1.74) Filipino (245)0.77 (0.51, 1.18)0.89 (0.58, 1.37)3.33 (1.49, 7.47)∗∗1.24 (0.85, 1.82) Japanese (169)1.27 (0.77, 2.09)0.67 (0.40, 1.13)1.53 (0.56, 4.20)1.15 (0.74, 1.81) Korean (101)0.98 (0.55, 1.75)0.88 (0.49, 1.59)1.55 (0.49, 4.92)1.52 (0.91, 2.53) NHOPI (260)1.07 (0.69, 1.68)0.63 (0.39, 1.00)3.16 (1.35, 7.37)1.42 (0.94, 2.14) Vietnamese (68)0.35 (0.19, 0.64)∗∗∗1.39 (0.75, 2.58)7.69 (2.93, 20.20)∗∗∗1.29 (0.76, 2.20) Other (313)1.27 (0.83, 1.94)0.67 (0.43, 1.03)1.60 (0.69, 3.72)0.85 (0.56, 1.28)∗∗P < .01; ∗∗∗P < .001. Only P values that reached significance (ɑ = 0.004) after Bonferroni correction were annotated.AA, Asian American; AIP, Asian Indian or Pakistani; aHR, adjusted hazard ratio; aOR, adjusted odds ratio; NHOPI, Native Hawaiian or Other Pacific Islander.∗ Multivariable analyses were adjusted with age, sex, histologic subtype, anatomic site, median household income, rurality, and geographic location, with stage at diagnosis and receipt of first-line surgery included as additional covariates in survival analyses.† Reference levels were selected based on known group with largest number of patients. Open table in a new tab ∗∗P < .01; ∗∗∗P < .001. Only P values that reached significance (ɑ = 0.004) after Bonferroni correction were annotated. AA, Asian American; AIP, Asian Indian or Pakistani; aHR, adjusted hazard ratio; aOR, adjusted odds ratio; NHOPI, Native Hawaiian or Other Pacific Islander. We identified significant differences in melanoma presentation and outcomes among disaggregated AA and NHOPI populations. The etiology of such differences is likely multifactorial and due to differences in healthcare access, cultural practices, sun-protective behaviors, and skin phototypes.3Shah N.S. Kandula N.R. Addressing Asian American misrepresentation and underrepresentation in research.Ethn Dis. 2020; 30: 513https://doi.org/10.18865/ED.30.3.513Crossref PubMed Scopus (44) Google Scholar, 4Supapannachart K.J. Chen S.C. Wang Y. Yeung H. Skin cancer risk factors and screening among Asian American individuals.JAMA Dermatology. 2022; 158: 260-265https://doi.org/10.1001/JAMADERMATOL.2021.5657Crossref PubMed Google Scholar, 5Dee E.C. Chen S. Santos P.M.G. Wu S.Z. Cheng I. Gomez S.L. Anti-Asian American racism: a wake-up call for population-based cancer research.Cancer Epidemiol Biomarkers Prev. 2021; 30: 1455-1458https://doi.org/10.1158/1055-9965.EPI-21-0445Crossref PubMed Scopus (28) Google Scholar AA and NHOPI populations also had higher rates of acral lentiginous melanoma, and thus differences in tumor biology may impact prognosis. Our results suggest that certain communities, including Filipino, NHOPI, and Vietnamese, may benefit from increased educational and preventative efforts to reduce late-stage diagnoses. Study limitations include small patient numbers in some groups and the inability to account for other potential confounders like healthcare access and utilization, education level, distance from facility, insurance status, and treatments. Further research is needed to better characterize melanoma outcomes in AA and NHOPI individuals and to identify potential targeted interventions to mitigate disparities. Mr Kim is a paid consultant at Verve Therapeutics and SeQure Dx, unrelated to this research. Dr Hartman is a scientific officer for Evereden, unrelated to this research. Mr Kim and Dr Hartman's interests were reviewed and are managed by Mass General Brigham in accordance with their conflict-of-interest policies. Drs Dee and Cheng have no conflicts of interest to declare.